The U.S. Centers for Disease Control and Prevention (CDC) reports that cigarette smoking in America has fallen in recent years. Many states have banned smoking in public venues and tolerance for smoking is ebbing. But at the same time the CDC reports that use of electronic cigarettes and hookah pipes have risen. The reason could be that users fail to realize these methods can be just as hazardous as cigarettes, or even more so.

Hookah smoking is increasingly popular among high school and college students. A 2012 Monitoring the Future survey found that 18.3 percent of high school seniors had used a hookah within the previous 12 months. Among college students, 22-40 percent say they’ve used a hookah during the last year. A survey of 105,000 college students conducted by the Nicotine and Tobacco Research Journal found that hookah was the most popular form of tobacco use right after cigarette smoking.

Hookahs, or water pipes, usually have a vase with water surrounding the pipe stem. At the top of the pipe hot coals are placed in a bowl where they heat flavored tobacco until it begins to smoke. Users then suck on a hose to draw the smoke down through the pipe stem and into the water. The smoke then rises above the water and enters the hose. Users puff on the hose to inhale the tobacco.

Many young people mistakenly believe that hookah use is safer than cigarette smoking. In fact, it has many shared risks. Hookah users are still inhaling the same 4,000 hazardous chemicals found in cigarette smoke. Filtering the smoke through the water does not remove cancer-causing polycyclic hydrocarbons, lung damaging volatile aldehydes, addiction-causing nicotine, heavy metals or carbon monoxide which can lead to cardiovascular disease.

Studies have shown that it takes about 10 puffs to smoke a cigarette, yet a one-hour hookah session involves 100 puffs. Each hookah puff contains 10 times the volume of a single cigarette puff, which means that during a hookah session a person inhales 100 times the volume of a single cigarette. One public service ad compared a one-liter soda bottle to the amount of smoke inhaled with just one cigarette. The ad then explained that hookah users inhaled 100 of those soda bottles during a single 45-minute session.

Hookah use is not benign. It is not safer than cigarette smoking. And it holds the same potential for addiction.

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